Variations in Cesareans, VBACs and Midwife Availability by County and by Hospital

Overall Cesarean Rates

The total number of cesarean deliveries in New York State in 2007 in the subset we analyzed was 85,244 (34.0 percent of the 250,780 deliveries for which the method of birth is known in the state that year[1].

Cesarean rates in New York vary more than 2.5-fold by county, ranging from a low of 16.6 percent for Cayuga County to a high of 43.1 percent for Westchester County (See Table 1). Cayuga has only one hospital performing deliveries and that is a Level 1 hospital without a neonatal intensive care unit (NICU); the rate therefore reflects practices in a single institution. Westchester, however, has eight hospitals, and the rates vary more than twofold among hospitals: from 25.2 percent to 52.7 percent.

Even wider variations are seen among hospitals within the state and within each county (See Table 2).

The 10 hospitals with the lowest overall cesarean rates are:

Auburn Memorial Hospital (16.6 percent)

North Central Bronx Hospital (18.5 percent)

Ellis Hospital - McClellan Division (18.7 percent)

Seton Health System - St. Mary's Campus (20.4 percent)

Samaritan Medical Center (20.6 percent)

St. Barnabas Hospital (20.7 percent)

Maimonides Medical Center (20.9 percent)

Good Samaritan Hospital of Suffern (21.2 percent)

Mary Imogene Bassett Hospital (22.3 percent)

New York Downtown Hospital (22.3 percent)

The weighted average for all deliveries of the 10 hospitals with the lowest overall cesarean rates is 20.8 percent.

The 10 hospitals with the highest overall cesarean rates are:

St. Anthony Community Hospital (53.3 percent)

Lawrence Hospital Center (52.7 percent)

Good Samaritan Hospital Medical Center (49.1 percent)

St. Catherine of Siena Hospital (49.0 percent)

Westchester Medical Center (47.5 percent)

St. Charles Hospital (47.3 percent)

Sound Shore Medical Center of Westchester (47.0 percent)

Claxton-Hepburn Medical Center (46.8 percent)

Plainview Hospital (46.7 percent)

St. John’s Riverside Hospital - St. John’s Division (45.1 percent)

The weighted average for the 10 hospitals with the highest overall cesarean rates is 48.3 percent.

The 10 hospitals with the lowest overall cesarean rates include rural and urban hospitals and are located in the following counties: Cayuga, Bronx, Schenectady, Rensselaer, Jefferson, Kings (Brooklyn), Rockland, Otsego, and New York.

Similarly, the 10 hospitals with the highest rates include hospitals from rural and urban areas and are located in the following counties: Orange, Westchester, Suffolk, Saint Lawrence, and Nassau.

As indicated above, the average cesarean rate in the 10 hospitals with the highest rates is 48.3 percent. This rate is 2.3 times higher than the average for the 10 hospitals with the lowest rates (20.8 percent). It is interesting to note that the level of maternal-infant care (RPC, Levels 1, 2, or 3) for the 10 hospitals with the lowest cesarean rates (1, 2, 2, 1, 2, 3, RPC, 2, 1, and 2, respectively) was almost identical to that for the 10 hospitals with the highest rates (1, 2, 2, 2, 1, 2, 3, 1, 2, and 2, respectively).

If the average cesarean rate for New York hospitals in our subset were 20.8 percent ― that is, equal to the average cesarean rate for the 10 hospitals with the lowest rate ― only 52,162 women out of the 250,780 who delivered with method of birth was known would have delivered via cesarean section. This means there would have been 33,082 fewer cesareans that year than the 85,244 that actually were done. Thus, more than one-third of the cesarean sections in New York in 2007 may well have been unnecessary.

Primary Cesarean Rates

Primary cesareans — defined as cesarean delivery among women who have not had a previous cesarean — are considered a more accurate indicator of current practice than overall cesareans because the overall cesareans also reflect the now almost automatic repeat cesarean in women who have had one previously.

The primary cesarean rate is computed by dividing the number of women having a cesarean for the first time by the total number of deliveries by women who have never had a cesarean section. Women who have had prior cesareans or a VBAC are thus subtracted from the denominator in computing the rate.

In New York, VBACs and repeat cesarean sections may be undercounted. The primary cesarean rate may therefore have a larger denominator than is warranted, thus yielding a lower rate than the “true” one. Our numbers may therefore err on the conservative side, understating the primary cesarean rate.

Rates by CountyThe primary cesarean rate in New York is 21.1 percent and varies more than 3.5-fold by county. County-specific rates range from 7.5 percent (Cayuga County) to 26.4 percent (Westchester County); these two counties also represent the extremes for total cesareans in general (See Table 1).

Individual Hospital RatesEven wider variations are seen between hospitals within the state (See Table 2).

The 10 hospitals with the lowest primary cesarean rates are:

Auburn Memorial Hospital (9.9% percent)

Phelps Memorial Hospital Assn (12.0 percent)

St. Barnabas Hospital (12.2 percent)

Brookhaven Memorial Hospital Medical Center Inc (12.2 percent)

Samaritan Medical Center (12.3 percent)

Ellis Hospital - McClellan Division (12.4 percent)

North Central Bronx Hospital (12.4 percent)

Seton Health System - St. Mary's Campus (13.2 percent)

Catskill Regional Medical Center (13.4 percent)

Good Samaritan Hospital of Suffern (13.8 percent)

The weighted average for the 10 hospitals with the lowest primary cesarean rates is 12.6 percent.

The 10 hospitals with the highest primary cesarean rates are:

Lawrence Hospital Center (40.3 percent)

Good Samaritan Hospital Medical Center (38.6 percent)

St. Anthony Community Hospital (38.6 percent)

St. Catherine of Siena Hospital (37.5 percent)

Sound Shore Medical Center of Westchester (37.4 percent)

Westchester Medical Center (35.5 percent)

St. John’s Riverside Hospital - St. John’s Division (35.3 percent)

New York Presbyterian - New York Weill Cornell Center (34.8 percent)

Claxton-Hepburn Medical Center (34.6 percent)

St. Charles Hospital (34.5 percent)

The weighted average for the 10 hospitals with the highest primary cesarean rates is 36.4 percent.

The 10 hospitals with the lowest primary cesarean rates include rural and urban hospitals in the following counties: Bronx, Cayuga, Westchester, Suffolk, Jefferson, Schenectady, Rensselaer, Sullivan, and Rockland.

Similarly, the 10 hospitals with the highest rates include hospitals from rural and urban areas in the following counties: Orange, Westchester, Suffolk, New York, and Saint Lawrence.

As indicated above, the average primary cesarean rate in the 10 hospitals with the highest rates is 36.4 percent. This rate is 2.9 times higher than the average for the 10 hospitals with the lowest rates (12.6 percent).

VBACs

Because of concerns about increased complications with some VBACs[2] and several high-profile cases in which women undergoing a VBAC ruptured their uterus, the American College of Obstetrics and Gynecology revised its guidelines in 1999 and in 2004 and adopted more restrictive conditions for the performance of VBAC. These guidelines require that institutions performing the procedure be “equipped to respond to emergencies with physicians immediately available to provide emergency care.”[3] Some have interpreted this to mean having an anesthesiologist available 24/7, while others have adopted a time span (15, 20, or 30 minutes) within which staff must be available. Hospitals that do not meet this standard have stopped doing VBACs: nationally, that means that 28 percent of hospitals that have labor and delivery wards did not allow VBACs in 2009. And an additional 21 percent of hospitals have “de facto” bans because, even when they have no official policy against the procedure, they have no obstetricians who will perform them.[4] Since 1996, approximately one-third of hospitals and one-half of physicians no longer offer a trial of labor to women with a prior cesarean.[5]

The VBAC rate in New York is 9.3 percent, higher than that for the country as a whole, which is 8.0 percent. As expected, within New York this rate varies by hospital, county, level of perinatal care, and size of hospital. Nineteen of the 143 hospitals we examined, accounting for 13.3 percent of the total, did not report performing VBACs in 2007. Among those that performed this type of delivery, the VBAC rate varied more than 900-fold, from .03 percent to 28.13 percent.

Rates by CountyCounty-specific VBAC rates among those counties with at least one hospital performing VBACs vary more than 19-fold, from 1.1 percent in Oswego County to 21.1 percent in Rensselear (See Table 2).

The 19 hospitals with VBAC rates of 0.0 percent are:

Adirondack Medical Center - Saranac Lake Site

Aurelia Osborn Fox Memorial Hospital

Bon Secours Community Hospital

Chenango Memorial Hospital, Inc.

Cortland Regional Medical Center, Inc.

Eastern Niagara Hospital - Lockport Division

Eastern Niagara Hospital - Newfane Division

Edward John Noble Hospital of Gouverneur

Glens Falls Hospital

Lakeside Memorial Hospital

Medina Memorial Health Care System

Memorial Hospital of William F. and Gertrude F. Jones

Nathan Littauer Hospital

Richmond University Medical Center

Rome Memorial Hospital, Inc.

Schuyler Hospital

Sound Shore Medical Center of Westchester

Westfield Memorial Hospital, Inc.

White Plains Hospital Center

The 10 hospitals with the highest VBAC rates are:

Seton Health System-St. Mary's Campus (34.4 percent)

North Central Bronx Hospital (30.9 percent)

Maimonides Medical Center (30.0 percent)

Harlem Hospital Center (28.1 percent)

Good Samaritan Hospital of Suffern (23.9 percent)

Northern Dutchess Hospital (22.9 percent)

Jacobi Medical Center (22.3 percent)

Samaritan Medical Center (22.2 percent)

Staten Island University Hospital - North (21.9 percent)

NYU Hospitals Center (21.4 percent)

The average for the 10 hospitals with the highest VBAC rates is 25.4 percent. This average is 2.7 times higher than the state average VBAC rate of 9.3 percent.

The 10 hospitals with the highest VBAC rates are located in New York County, Bronx, Kings (Brooklyn), as well as hospitals in Dutchess, Jefferson and Rensselear counties. Other counties with at least one hospital performing VBACs on at least 15 percent of women with a previous cesarean section include Monroe, Rockland, and Wayne counties.

Midwife Deliveries in Hospitals

While midwives attend 7.0 percent of all births in the United States, they attended 9.6 percent of all deliveries in New York State in 2007.

As is the case with overall and primary cesarean rates and VBAC rates, there is enormous variation among counties in New York in the availability of midwife deliveries. The rates ranged from 0.0 percent in several counties (no hospitals providing midwife deliveries) to 58.2 percent in Warren County (See Table 1).

Even wider variations in midwife deliveries are seen among hospitals within the state (See Table 2).

In New York, 44 hospitals do not provide midwife-attended births; these are:

Albany Medical Center Hospital

Alice Hyde Medical Center

Bon Secours Community Hospital

Brookhaven Memorial Hospital Medical Center, Inc.

Brooks Memorial Hospital

Chenango Memorial Hospital, Inc.

Claxton - Hepburn Medical Center

Corning Hospital

Eastern Niagara Hospital - Newfane Division

Edward John Noble Hospital of Gouverneur

F. F. Thompson Hospital

Faxton - St. Luke’s Healthcare St. Luke’s Division

Flushing Hospital Medical Center

Geneva General Hospital

Good Samaritan Hospital Medical Center

Lawrence Hospital Center

Lenox Hill Hospital

Lewis County General Hospital

Lincoln Medical & Mental Health Center

Long Island Jewish Medical Center

Massena Memorial Hospital

Mount St. Mary’s Hospital and Health Center

New York Downtown Hospital

New York Hospital Medical Center of Queens

New York Presbyterian - New York Weill Cornell Center

New York Presbyterian Hospital - Columbia Presbyterian Center

Niagara Falls Memorial Medical Center

Nicholas H. Noyes Memorial Hospital

Oneida Healthcare Center

Peconic Bay Medical Center

Queens Hospital Center

Richmond University Medical Center

St. John’s Riverside Hospital - St. John’s Division

Sound Shore Medical Center of Westchester

Southampton Hospital

Southside Hospital

St. Anthony Community Hospital

St. James Mercy Hospital

Strong Memorial Hospital

University Hospital of Brooklyn

Westchester Medical Center

Westfield Memorial Hospital, Inc.

Woman's Christian Association

Wyckoff Heights Medical Center

The 10 hospitals with the highest percentage of midwife deliveries are:

North Central Bronx Hospital (79.8 percent)

Mary Imogene Bassett Hospital (70.1 percent )

Woodhull Medical & Mental Health Center (69.5 percent)

Glens Falls Hospital (58.2 percent)

Rome Memorial Hospital, Inc. (55.7 percent)

Seton Health System-St. Mary's Campus (52.7 percent)

Community-General Hospital of Greater Syracuse (51.3 percent)

Phelps Memorial Hospital Association (50.2 percent)

Schuyler Hospital (47.1 percent)

Catskill Regional Medical Center (44.8 percent)

The average for the 10 hospitals with the highest percentage of midwife deliveries is 62.0 percent. This rate is 6.5 times higher than the state average percentage of hospital deliveries done by midwives (9.6 percent). It should be noted that midwife-assisted deliveries are widely available in both rural and urban settings.

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